Slow Medicine

Time heals all wounds, they say, or, in medicine, if not all, then many. But with our improved efficiency and throughput of patients, we fail to allow this most magical treatment to work. The pace and intensity of medicine has increased exponentially over the past several decades. We see more doctors, have more procedures, take more medications, and all without significant improvements in overall population health. I have seen many patients who are referred for a test to evaluate a symptom, but because of scheduling delay, by the time they are able to take the test, the symptoms have spontaneously resolved.

Even in the past decade or so there has been an escalation as the efficiency of ordering and delivering medical care has improved. I remember when it took 24-48 hours to get an echo (ultrasound of the heart). Today, I can order one in the ICU in the middle of the night and have it done with preliminary results within an hour. Perhaps the care is better as a result. Perhaps it doesn’t make any difference.

What I do know is that we order more echos than we used to, and more echos than we would if it weren’t possible to get them that quickly. Chances are that at least some of the patients who now get echos immediately would have improved so as not to require that test had we had to wait 24-48 hours. And perhaps there are some for whom that middle of the night echo makes all the difference. The trouble is, we can’t predict which of our patients would benefit and which would not need it.

In the Emergency Department, especially, when patients come with worrisome or vague complaints, a quick scan can settle the question, rather than observation, or god forbid, talking to the patient more. The particular calculus may well be that getting a scan is more cost effective than hanging out in the ED for hours, but it turns out that when you can get a CT scan in 15 minutes, you get more of them. Why not? If someone has to drive 2 hours for a CT, well then, we make do with less.

It isn’t just that doctors are trigger happy. It is also the local environment. If something goes wrong, and statistically something eventually will, then your colleagues will ask you why you didn’t “just” get the CT in this patient? But if the nearest scanner is 2 hours away, then the local practice is less likely to be reliant on CTs, and colleagues are less likely to question why a scan wasn’t done. This is why patients evaluated for the same complaints end up getting more testing in the ED than if seen in a clinic, and why some insurance cost-cutting measures are designed to keep us out of the ED and shuttle us to clinics or urgent care settings.

There are other problems with “just” getting the scan. We find things. We find lung nodules, adrenal nodules, thyroid nodules, kidney and liver nodules, thickening of the gastrointestinal tract, calcifications of the coronary arteries, and many other “incidental findings,” that are likely benign and of no consequence, but we cannot be sure. So we biopsy them, we get more scans to follow them, check blood tests, and then we find other possible things that on further evaluation are nothing, and now we’re down this endless road of chasing our tails.

Don’t get me wrong, I’m not arguing that we let people flounder, but at some point the speed of modern medicine has outpaced the pace at which our bodies recover from disease. We may be just spinning our wheels while nature takes its course. As Voltaire put it, “The art of medicine consists of keeping the patient amused while nature heals the disease.” But our distractions are ever more intensive and ever more expensive. The trick, of course, is figuring out when our speed is working against us, and when it is truly beneficial, and essential, for our patients’ health. We don’t have it figured out yet.

So what should we do? I won’t claim to have the answers, but we can’t expect our doctors to ration care at the bedside. When my doctor sees me, I don’t want them to think about how many tests they need to order to pay their bills that month any more than I want them thinking about how many tests they should avoid ordering to help the national debt. At the patient-doctor interaction, it has to be personal. My doctor should feel it’s unethical to withhold a treatment she believes works. But perhaps the best way we can manage these conflicts as a society is to demand, and participate in, reproducible, high-quality scientific studies to allow physicians to base their beliefs of an intervention’s efficacy on real data.

And maybe, just maybe, like the move toward “slow food,” we can move toward “slow medicine.” More time talking to patients, more time listening, and less time running around ordering tests and doing stuff. “Don’t just do something, stand there,” a senior resident told me when I was an intern. “Slow medicine,” won’t provide all the answers, but it’s a safe bet more listening and less testing would improve the patient and doctor interaction, and likely all of our overall satisfaction with our healthcare system.

Comments

One of my cherished mentors in Cardiothoracic Surgery, W. Sterling Edwards, MD, used to have a saying: “If you just listen to a patient long enough (and keep your preconceived diagnoses to yourself), they will tell you what’s wrong with them.” After he retired from surgery, he spent the rest of his career “listening” to patients. Out of this endeavor developed a course taught to first year medical students at UNM called “How to Listen to a Patient”. In my career I found Dr. Edwards to be right. If you indeed listened to a patient, they will often tell you what’s wrong with them. The art here is: how to listen, a principle the Chief was always teaching us while on rounds. Listening, then, can sometimes help the clinician to better narrow the spectrum of tests ordered and thus save money while still rendering excellent care—merely by listening. I must admit, though, the System doesn’t always permit us to listen in the manner that we would like. A conundrum!

I thought co-pays were supposed to make people think twice about opting for a procedure. Oh well, if people knew how much CT was irradiating their bodies, they would definitely think twice before jumping in. My personal rule is CT only in emergencies, thank you 😉